APPLICATION PACKET - Florida

1 APPLICATION PACKET CDC+ APPLICATION Instructions CDC+ APPLICATION Hiring and Working with Your Consultant Questions you can ask when interviewing a Consultant New Consultant Evaluation Form CDC+ Participant/Consultant Agreement Representative Agreement APPLICATION Instructions Revised 2015-12-10 CDC+ APPLICATION Instructions Please follow the instructions below in order to fill out the CDC+ APPLICATION . You will need to obtain a copy of your most current Support Plan and cost plan in order to fill out all sections of this form.

2 Be sure to print all information in capital letters. Section I - PARTICIPANT 1. Fill in the participant s legal first name, last name, and middle initial. Do not enter a nickname or abbreviation. 2. Obtain the participant s (consumer s) Medicaid ID number. This 10 digit number may be found on your Support Plan or obtained from your Waiver Support Coordinator. 3. Be sure to complete the participant s date of birth, gender, and race. 4. Participant s primary language should be English unless the participant cannot speak English. 5. Please provide the language in which you need your written materials.

3 Section II PARTICIPANT S LEGAL STATUS 1. If the participant is a minor (under 18 years of age) and has parents, then the parents are the guardian. If someone else is the legal guardian, please check Other Legal Guardian . 2. If the participant is an adult (18 years of age or over) he or she must either be a competent adult or have a legal representative. If a parent of an adult has not been appointed legal representative through the court system, they are not considered that person s legal representative. Please ask your Waiver Support Coordinator if you have any doubts.

4 Section III CDC+ REPRESENTATIVE 1. This section is to be completed ONLY if the participant has selected a person to be his or her CDC+ representative. This is NOT the same as a legal representative (although it can be the same person). Please refer to the Glossary of Terms for additional information. 2. The representative must attend the CDC+ training and pass a Readiness Review in order to be the participant s official representative. 3. Be sure to check the relationship of the representative to the participant. 4. Representative s primary language should be English unless the participant cannot speak English.

5 Please provide the language in which you need your written materials. Section IV CDC+ CONSULTANT SELECTION 1. You must select a Waiver Support Coordinator who is trained as a CDC+ Consultant. Please obtain a list of trained CDC+ Consultants from your local APD Office. Section V CDC+ COST PLAN 1. This section may be completed by you or your Waiver Support Coordinator/CDC+ Consultant. 2. The information for this section can be obtained from your most current/approved cost plan. Signatures 1. If the participant is a minor, the parent or legal guardian will sign the top line.

6 If the participant is a competent adult, the participant needs to sign. If the participant has a legal representative, the legal representative must sign. 2. Your Waiver Support Coordinator will also sign this form. AGENCY FOR PERSONS WITH DISABILITIES CONSUMER DIRECTED CARE PLUS (CDC+) APPLICATION 1 of 2 CDC+ APPLICATION Form Effective Date: 09/2/2014 SECTION I PARTICIPANT Participant s First Name MI Participant s Last Name Participant s Social Security Number Participant s Date of Birth / / Participant s Medicaid ID Number Participant s Gender Male Female Participant s Race White Black Indian or Alaskan Native Asian Latin/Hispanic Other: _____ Participant s Mailing Address.

7 Mailing Address Line 2 City State Zip Code F L County of Residence Home Phone Number ( ) _ Alternate Phone Number Fax Number ( ) _ ( ) _ Participant s E-mail Address Participant s Primary Language Written Materials Language if other than English SECTION II PARTICIPANT S LEGAL STATUS Minor: Parental Guardian Adult: Legal Representative has authority over medical decisions and/or government benefits Minor: Other Legal Guardian Competent Adult.

8 No Legal Guardian Guardian/Legal Representative s First Name, Middle Initial, Last Name (If none, leave blank) Guardian/Legal Representative s Mailing Address City State Zip Code Home Phone Number Alternate Phone Number ( ) _ ( ) _ AGENCY FOR PERSONS WITH DISABILITIES CONSUMER DIRECTED CARE PLUS (CDC+) APPLICATION 2 of 2 CDC+ APPLICATION Form Effective Date: 09/2/2014 Participant.

9 _____ SECTION III CDC+ REPRESENTATIVE (IF NOT NEEDED, LEAVE BLANK) Representative First Name MI Representative Last Name Representative s Legal Mailing Address City State Zip Code Representative s Home Phone Number Cell Phone Number ( ) ( ) Work or an Alternate Phone Number Fax Number ( ) ( ) Representative s E-mail Address Relationship to Participant Parent Spouse Other Relative Friend Representative s Primary Language Written Materials Language if other than English SECTION IV CDC+ CONSULTANT SELECTION Consultant s First Name Consultant s Last Name Consultant s Agency Name (If solo practitioner, enter SOLO )

10 Consultant s Email Address SECTION V IBUDGET COST PLAN (TO BE FILLED OUT BY YOUR CONSULTANT) Most Recent Support Plan Date iBudget PIN / / Current Cost Plan Dates: / / To / / Consumer/Guardian/Legal Rep Signature Date Print Name Consultant Signature Date Print Consultant Name Hiring and Working with Your Consultant Revised: 2015-12-10 Hiring and Working with Your Consultant When hiring a consultant, you should interview potential candidates to find the right person for the job.